Incisional hernia repair after abdominal organ transplantation: current evidence, controversies and research gaps

Incisional hernia is a common late complication of abdominal organ transplantation, with reported frequency ranging from a pooled 4% after kidney transplantation to a prevalence of 43% on clinical examination after liver transplantation. Immunosuppression places recipients at least in Ventral Hernia Working Group grade 2, and concern about wound failure, mesh infection and recurrence often delays repair. This mini review synthesises evidence on elective repair in adult liver, kidney and pancreas recipients around three questions: whether transplant status independently predicts adverse outcome, how immunosuppression relates to outcome, and how operative access, reconstruction, mesh plane, material and fascial closure should be chosen. In most registry and matched comparisons, 30-day wound morbidity and length of stay were similar to those of non-transplant patients, although one matched laparoscopic series found more surgical site occurrences. Study-specific recurrence ranges from 0% in selected specialist series to 37%, with differing follow-up and ascertainment, and observational comparisons do not establish whether transplantation independently increases recurrence. A randomised trial showed more wound complications with de novo sirolimus after kidney transplantation; the association between maintenance sirolimus and recurrence after later repair rests on small, conflicting series, and perioperative conversion is untested. Recent series of transversus abdominis release report recurrence of 0%–25%, depending on incision, defect size, follow-up and comparator. Diaphragmatic tack fixation should be avoided. Two randomised trials of prophylactic mesh at transplant closure are registered, without published results. Research priorities include transplant-specific registry fields, standardised recurrence ascertainment, longer post-repair follow-up and graft-related outcomes.